July 01, 2002, Pg. A01

For Psychiatrists, a Bitter Pill in New Mexico; Law Giving Psychologists Right to Prescribe Medications Spurs a Battle With MDs

By Shankar Vedantam

In his annual report to the nation's psychiatrists in May, the medical director of the American Psychiatric Association rallied America's psychiatrists "to stop this plague from spreading across the nation."

Steven Mirin was not referring to bacteria, a virus or a brain disease like Alzheimer's. The "plague" was a victory by psychologists in New Mexico, who recently won the power to write prescriptions for such psychiatric drugs as Prozac -- an authority generally limited to psychiatrists and other MDs.

A new law, which takes effect today, makes New Mexico the first state to give prescription-writing authority to psychologists -- talk-therapy experts who are not MDs. Observers say New Mexico's precedent could be the beginning of a fundamental change in how mental illness is treated across the nation, vastly increasing the number of patients receiving psychiatric medications. Studies show that many people with mental illness do not receive treatment, even as many others are given psychiatric pills they do not need.

The push by psychologists to obtain prescription-writing authority is also the clearest sign to date that the treatment of mental illness has swung away from insight-oriented Freudian talk therapy toward medications. This trend has been propelled by a new understanding of the biological basis of mental illnesses, a shift in research and insurance priorities toward drug treatment, and immense marketing efforts by the pharmaceutical industry. Research has shown that many patients with mental illnesses do best when given a combination of medicines and talk therapy.

For psychiatrists and psychologists, the New Mexico law and the precedent it has set across the nation have meant a brutal and expensive battle. Similar bills have been introduced in 11 other states in recent years. Psychologists and psychiatrists are battling it out in these states and two dozen more, raising money, frantically lobbying legislators and accusing each other of trying to make money at the expense of what's best for patients.

Psychologists who fought for the New Mexico law accuse psychiatrists of trying to protect a fiefdom. "A large part of it is a question of turf," said psychologist Elaine LeVine, who advocated passage of the New Mexico law. "It's the kind of power that comes with having a unique possession of a certain turf."

The psychiatrists retort that the New Mexico law was a "cynical, economically motivated effort" on the part of psychologists to obtain insurance reimbursements for treating patients with medicines.

It is not clear how much business psychologists will take away from psychiatrists. Indeed, the vast majority of prescriptions for psychiatric medications are already being written by non-psychiatrists -- primary-care physicians and other MDs prescribe most of these pills. And the handful of New Mexico psychologists who have signed up to prescribe the medicines may take a year or more to become certified.

Psychiatrists say they are opposed to the measure because it will harm patients. They warn that psychotropic medicines affect not only the brain, but all organs and systems of the body, sometimes with adverse effects. Some combinations of medicines are dangerous, and a psychiatrist -- or a primary-care physician who is an MD -- is much more likely to understand the effects of the medicine on the entire body, Paul Applebaum, president of the American Psychiatric Association, said in a recent interview.

Rather than train psychologists to write prescriptions, Applebaum suggested that a better solution would be to train primary-care physicians who are MDs to better diagnose and treat mental illnesses. As an example of a situation where psychologists could find themselves out of their depth, Applebaum cited a letter that all physicians in the country recently received about a mood stabilizer called Depakote, which is used to treat bipolar illness. The drug's manufacturer and the Food and Drug Administration warned doctors to be alert for side effects of liver toxicity.

"Any physician who gets that letter has a framework to fit that information," said Applebaum. "They understand liver function, the urea cycle, the signs of hepatic encephalopathy. Psychologists have none of that."

"You can learn all that," Applebaum said. "We call it medical school."

The New Mexico law allows prescriptions to be written by psychologists who have completed PhD programs, who have expertise in treating mental illness, and who undergo 450 hours of training in psychopharmacology and medicine. At first they do so under the supervision of a psychiatrist or another specialist.

LeVine said 12 psychologists, including herself, will finish the academic training by year's end and hope to finish the practical training and be certified by the end of next year. LeVine said the newly trained psychologists will sharply increase patients' access to treatment. Large numbers of patients who now see a psychologist for talk therapy and an MD for a prescription will be able to receive all the care they need from the same person, she said.

The American Psychological Association has made the issue a major priority. Russ Newman, the association's executive director for professional practice, said that organized psychiatry had long opposed the growth of psychology, having raised fears about psychologists' ability to provide safe inpatient and outpatient psychotherapy in earlier times.

"They are opposed to another profession that would then be in competition with them and expose consumers to greater choice," he said.

Newman said that psychologists began seeking prescription-writing authority in the mid-1980s. Hawaii was the first state to consider the issue. In 1991, the Department of Defense launched a pilot program to train psychologists to prescribe psychiatric drugs to military personnel, their families and retirees.

Ten psychologists were trained in the program. A report on the program by the American College of Neuropsychopharmacology concluded that psychologists could be safely trained to write prescriptions. The report said the 10 psychologists "filled critical needs, and performed with excellence wherever they were placed." The report, which is acknowledged by both psychiatrists and psychologists to be a comprehensive evaluation, added, however, that "there was essentially unanimous agreement that the graduates were weaker medically than psychiatrists."

The Defense Department discontinued the program, but seven of the psychologists are still writing prescriptions at military facilities, said Cmdr. John Sexton, one of the trained psychologists who works at the Naval Medical Center in San Diego.

Sexton estimates he has treated some 2,000 patients with various mental illnesses, from mild depression to bipolar illness and psychosis. He said that the training has helped him be a better care provider, even though he uses medicines sparingly. In an informal study, where he compared his own treatment against that provided by two psychiatrists, he found that the doctors trained in medical school prescribed medicines to 61 percent and 68 percent of their patients. He prescribed medicines to only 13 percent of his patients.

Sexton said his preference for psychotherapy was actively encouraged by the military, where active-service personnel could be discharged for being placed on psychotropic medicines.

"A psychologist who prescribes will more likely do psychotherapy and then use medications sparingly and as an adjunct to talk therapy," he said. "This is a good idea. Many of us feel that too many people put things in their bodies to escape pain in life, emotional or physical."

Psychotherapy, he said, arms patients with skills to deal with life's problems, "rather than setting them up to turn to a substance to get away from their problem. We're teaching the man to fish rather than handing them a fish."

It is unclear whether that preference would apply in the civilian world, where managed-care companies often do not cover comprehensive psychotherapy.

At a session on the issue at the recent convention of the American Psychiatric Association, a surprisingly wide range of views emerged. Scott Mendelson, a psychiatrist in Roseberg, Ore., said he had no problem with psychologists prescribing medicines for mild cases of mental illness.

"Let the psychologists have the worried well who can take Prozac," he said. "If someone's grandmother is delusional, they are going to see a psychiatrist. Let us do what we do best, as specialists."

But Jennifer Cooper, a psychiatry resident at New York-Presbyterian Hospital, warned that insurance companies would never reimburse psychiatrists' fees if they knew patients could just as easily get prescriptions from a psychologist. Michael Franz, a psychiatrist from Portland, expressed concern that medical students could be turned away from psychiatry.

Mark Suhany, a Las Vegas psychiatrist and a district chief for the American Psychiatric Association, said the issue clearly affects psychiatrists' income. Mounting an economic argument is "political suicide," he said, but it is essential to get psychiatrists to contribute money for a campaign. "This is an organization-versus-organization fight," he said. "And it is a fight."

An Ohio physician, Jill Fox, said, "This is going to make all of us look bad." Turning to her fellow doctors, she asked, "How can we make this a win-win situation?"

While some psychiatrists in the audience agreed with her, others would have none of it. Jeffrey Fahs, a North Carolina psychiatrist, retorted, "We don't remember Neville Chamberlain because he wanted a win-win with Hitler. I think we should fight this."

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